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dl j 1 <br /> Please print or type. k Approved.roved. OMB No. 2050.0039 <br /> J4 arm <br /> 1 , Generator Tr <br /> UNIFORM HAZARDOUS ID Number 2. Page 1 of 3. Emergency Response Phone 4. Me ea kl mer <br /> WASTE MANIFEST CAU 10133 x4766 €308 8" -7378 � � � � 832 JJ K <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> 1?310T 72AV" MMMS LW <br /> 5508 :U)NM DRXW FLYING a TRAM PLaAM 610 <br /> ttlMVT]rm>r. , 7W 37909 mol g _ arm TONE ROAD <br /> Generator's Phone: 865 474- 2626 Attn ' JC= I P RIPO CA 95366 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> ADS SERVICES , 319C . CAMO010 431 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> DIENIM01MUMN <br /> 2000 19 _ .+3►JAM MA STPJW- CA 7080013352 <br /> COWTIMI CA 50222 <br /> FaalilysPhone: .310 537 =7100 <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (ff any)) No. Type Quantity WLN01. <br /> 1 . <br /> o �CItA �tia ,LII38IYF <br /> R WX I &iX 155 TT <br /> z 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> • '4 <br /> 14. Special Handling Instructions and Additional Information <br /> AVOID EXT CONTACT 6 'BAR RU150fR &7d.1t ES ;A) MTEB WITH IfMOCARMS <br /> MPR : AWMS i anti Y <br /> 15, GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, S <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary <br /> i Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (d] am a small quantity generator) is we. <br /> Generator'slOfferoes Printedrryped Name Signature Month Day Year <br /> 16, International Shipments <br /> F ❑ Import to U.S. ❑ Export from U .S. Port of entry/exit: <br /> ? Transporter signature (for exports only): Date leaving U.S.: <br /> oC 17. TransporterAclmowiedgment of Receipt of Materials <br /> 6iTransporter 1 Printecirryped Name Signgture Month Day Year <br /> 0 � <br /> � <� r Ajl <br /> ' t , <br /> ZTra sporter 2 Printed yped Name Signature Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. ARemate Facility (or Generator) U.S. EPA ID Number <br /> J_ <br /> V <br /> ua Facililys Phone: GENERATOR Month Day Year <br /> Lu 18c. Signature of Alternate Facility (or Generator) <br /> Q <br /> your It is r res onsibility to make a copy <br /> 19, Hazardous Waste Report Management Method Codes (i.e. y p <br /> c 1 . 2. of this "Generator' s Initial Copy" and 4* <br /> mail it within 30 days to : <br /> 20, Designated Facility Owner or Operator: Certification of reoe DTSC Generator Manifests <br /> Printed/typed Name P . O . Box 400 � Month Day Year <br /> Nr 1 <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsc Sacramento , CA 95812 GENERATOR' S INITIAL COPY <br />